Provider Demographics
NPI:1437484599
Name:MOLLICA, SAMANTHA JOY (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JOY
Last Name:MOLLICA
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W CAMDEN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-7912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:HALSTED 153
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-1900
Practice Address - Country:US
Practice Address - Phone:410-955-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered